Dr. Ray and Dr. Bobby Ghaheri discussing the latest research onanterior and posterior tongue-ties.
FRENECTOMIES – LIP-TIE AND TONGUE-TIE REVISIONS
- Same day treatment available
- No referral needed for an evaluation
- In-network with most major dental insurances, and able to assist with filing to medical insurance companies
- CO2 laser for safest and most comfortable experience for your babies and children
- No worrying about re-attachments! We offer free revisions for up to 1 year from original date of surgery
- Services provided by a knowledgeable and seasoned pediatric dental specialist
As a parent of a child with a tongue tie, Dr. Ray knows how important it feels to make the right decision for the benefit of your child. Our role is to help you make an informed decision while still advocating for your child’s right to a happy and healthy experience. You’ve got questions. We’ve got answers. Let’s get started, together.
What is a Frenectomy? Who needs one?
Approximately 4-10% of children are born with some degree of frenulum restriction, also known as tongue-tie or lip-tie. This means that their tongues and lips are attached to the mouth with excessive connective tissue webbing. This excess tissue impedes the movement of the tongue or lips to various degrees, and may be responsible for minor inconveniences such as the inability to lick your ice cream cone, to more severe impairments such as problems breastfeeding, or impediments to speech development.
When this restricted mobility interferes with nursing, bottle feeding, or causes discomfort to mother or child, a frenectomy (cutting/release of the restrictive tissue) may be recommended for infants. Children who are going through speech therapy may also find that a frenectomy is indicated, as it may help with movement of the tongue, and subsequently result in significant improvements in speech therapy.
Our diagnosis and treatment planning protocols, as well as our treatment philosophy, are informed by a variety of sources, including significant information from:
- Dr. Bobby Ghaheri, MD (DrGhaheri.com) who is an ENT and leading authority on tongue and lip ties;
- Dr. Lawrence Kotlow – Pediatric Dentist and author/founder of the Kotlow classification system for tongue and lip ties;
- up-to-date peer-reviewed scientific literature.
The reason this is important is because we believe that our role is to educate parents and evaluate children for lip and tongue-ties that are causing problems. We want parents to know that we have committed ourselves to the latest studies and philosophies that allow us to make sure we are putting babies and children through procedures that are necessary, useful, and that have the potential to improve the babies quality of life.
Not every baby needs a revision, and we will always be thorough and thoughtful with parents to explain our findings and our rationale to engage, or not engage, in treatment.
What are the symptoms?
Symptoms are going to vary in every infant, child and adult. The decision to revise is based on the presence of symptoms, or the possibility of future symptoms. As a practice based in science, it’s important to understand that the vast majority of these symptoms are possibilities, but that there is not a lot of scientific evidence to support that. Does it mean that it’s not true? No, not necessarily, but your results may vary when you decide to do a revision or not.
Tongue and Lip Tie symptoms in babies and young children:
- Significant problems with breastfeeding
- Inability to extend tongue past lips, lift the tongue fully upwards or move it side to side
- Speech problems, delays and/or lisps
- Choking, gagging and/or vomiting on liquids and/or foods
- Picky eater, may have solid food aversions, preferring purees and/or very soft foods
- Dribbling and/or mouth breathing
- Digestive problems, constipation, reflux
- Headaches and/or migranes
- Dental and oral health problems including cavities, gum disease and/or bad breath
- Food may fall out of mouth, child may gag, food trapping in the palate and/or cheeks next to gums
- Sleep apnea and/or sinus problems
- Behavior problems
- Self esteem problems/loss of self confidence to do different appearance and/or symptoms
- Heart shaped tongue
- Difficulty swallowing
- Difficulty maintaining correct posture
- Trouble eating lumpy foods and/or certain textures
- Inability to eat age appropriate foods
- Inability to chew age appropriate solid foods
- Gagging, choking or vomiting foods
- Persisting food fads
- Difficulties related to dental hygiene
- Persistence of dribbling
- Delayed development of speech
- Deterioration in speech
- Behaviour problems
- Loss of self confidence because they feel and sound ‘different’
- Strong, incorrect habits of compensation being acquired
For adults who are in need of a frenectomy but do not pursue it, later complications may include a variety of symptoms including:
- Inability to open the mouth widely affects speech and eating habits
- Always having to watch their speech
- Inability to speak clearly when talking fast/loud/soft
- Difficulty talking after even moderate amounts of alcohol
- Clicky jaws
- Pain in the jaws
- Protrusion of the lower jaws, inferior prognathism
- Multiple effects in work situations
- Effects on social situations, eating out, kissing, relationships
- Dental health, a tendency to have inflamed gums, and increased need for fillings and extractions
- Sensitivity about personal appearance
- Emotional factors resulting in rising levels of stress
- Tongue tie in the elderly often makes it difficult to keep a denture in place
Some of these symptoms or side effects are supported by hard science. For instance, there is a significant amount of literature that infants that have restrictive tongue or lip ties can have a significantly greater experience of a laser frenectomy is complete early on. This finding is supported by both scientific literature, as we as a treasure trove of anecdotes from happy moms.
What about behavior problems for children with a tongue or lip tie?
This symptom, along with many other symptoms are supported by anecdotal evidence, some with overwhelming anecdotal evidence. However, no long term, well-designed studies have been completed and published yet. That is not to say there is not a link- it just has not been proven to be associated or not. In these instances, Dr. Ray and parents will make decisions based on symptoms and the possible costs/benefits that may occur.
I THINK MY CHILD MAY HAVE A LIP/TONGUE TIE.
Do I need a referral?
NO – you do not need to have a referral to have an exam and consultation for lip/tongue tie revision. However, we strongly recommend that you eventuallyt have a team of professionals to help with alieving symptoms- we are able to help you find an appropriate team that will help you. Dr. Ray will complete your consultation, and ask you about your medical providers and other professionals who may be involved in addressing your concerns – this can include pediatricians, lactation consultants (IBCLC), speech therapist, chiropractor, etc.
When it comes to children, High House Pediatric Dentistry encourages a team approach and good communication to your child, whether it’s dental caries, or problems breastfeeding, or delayed speech development. For parents with infants who are having problems breastfeeding, we strongly encourage you to speak with your IBCLC and let them know that you are considering a frenectomy procedure. It takes a village- and we want to make sure we are all in agreement on the best way to proceed for your child.
SO HOW DO I DECIDE?
The decision to get a TT or LT revision is based solely on the decision of the parent(s). Every parent wants to make the “right” choice. But, the answer will vary depending on what symptoms are present, and what the parent hopes to achieve with a revision. Dr. Ray will help parents to make an informed decision, and to understand what expectations are supported by science, and what expectations are more anecdotal in nature. In either case, Dr. Ray invites parents to ask questions so that everyone is on the same page when it comes to expectations before, during, and after surgery.
However, there is not always peer-reviewed scientific literature to back up these claims. In these situations, Dr. Ray will ask parents if they’ve tried other reasonable treatment options, and also determine what the expectations of the parent are after revision. Parents must weigh the possible benefits (increased tongue mobility, easier breastfeeding, resolution of speech problems) with the costs of having a revision (discomfort/pain management for infants, frequent stretching sessions, even in the middle of the night, adjustment period for breastfeeding where transfer and pain may actually worsen before getting better).
Even when the procedure is a complete success, there is a chance that re-attachment may occur, and subsequently the need for a second surgery. HHPD is happy to be the only provider that includes a free revision in the case of re-attachment, however parents must understand that even under the best circumstances, there are children who undergo this procedure 2-3 times to achieve the desired result.
WHY DO WE NEED A LASER? WHY IS YOUR LASER DIFFERENT?
Lasers have a much better safety profile compared to surgical scissors- sterilization on contact, less pain, less scar tissue, and shortened healing time. But. are all lasers created equal? The answer is no. Because we work with infants, and consistent with our philosophy of never “cutting corners” for our patients, HHPD seeks to use the laser with the absolute best safety profile for all patients. We use a CO2 laser manufactured by Light Scalpel. The LightScalpel represents the safest technology among lasers being currently being used in North Carolina.
The most common type of laser used for frenectomies by preferred providers in NC is the diode laser, which is essentially a “hot knife” that cuts and cauterizes blood vessels as it moves through the tissue. These lasers operate at temperatures in excess of 600F, and must make contact with the tissue in order to cut it. Lasers have a much better safety profile compared to conventional use of surgical scissors, specifically with regard to the scar tissue formed. Our lightscalpel CO2 laser was chosen because it has several safety advantages over conventional diode lasers. These include:
- Lower operating temperature (96*F versus 600*F for diode lasers)
- Significantly less penetrance past the point of incision compared to diode lasers – this results in less scar tissue formation and associated complications
- Less dissipation of heat to surrounding tissues compared to diode lasers – because the lightscalpel does not actually touch the tissue, it has less chance of heat-damage to muscles, blood vessels, and surround structures
WHY IS A CO2 LASER BETTER THAN A DIODE LASER?
A variety of lasers are available for use for soft tissue purposes. While there are hard tissue lasers as well, these are irrelevant in relation to tongue-tie and lip-tie revisions. Which laser is your doctor using? Most doctors use a diode laser, similar to a “hot knife”. This diode laser placed on the frenum/frenulum, and a cutting motion is made until the tissue is cut and cauterized.
At High House Pediatric Dentistry, we chose to use the LightScalpel CO2 laser for tongue-tie and lip-tie revisions in infants and children. The CO2 laser is a true laser, and thus does not touch the tissue at all. The frenum dissolves in a few seconds, with negligible bleeding and discomfort. HHPD is proud to be one of only 3 practices in North Carolina with this laser, which exhibits the highest safety profile for our youngest guests.
At High House Pediatric Dentistry, patient safety and comfort is our highest priority, and we use equipment that insures that our patients at makes a CO2 laser better than a diode laser.
- LESS HEAT – Diode lasers operate at upwards of 500 degrees Celsius. Our CO2 laser operation is approximately 80% cooler (with regards to both temperature, and style points). This significantly reduces the risk of heat damage or collateral damage to surrounding nerves and tissue.
- LESS TISSUE DAMAGE – Compared to scissors, lasers as a whole have a proven track record of better healing and fewer complications. But not all lasers are created the same! Traditional diode lasers cut by actually contacting the tissue, and releasing heat to surrounding tissues, up to 8mm.The CO2 laser cuts to only 0.1mm, almost 99% shallower. Once the energy hits the tissue, the energy is dissipated, protecting the muscle, nerves, and deep tissue that can be painful if damaged. For our infant patients, this was one of the primary reasons for selection of this laser.
- LESS BLEEDING – Use of CO2 lasers has been shown to be the best choice for hemostasis (Azevedo et al, 2016). In a study of laser treatment of tongue lesions, Diode lasers caused significant damage while CO2 lasers had minimal damage and outstanding hemostasis, resulting in less bleeding. Why does this matter for your child? Less bleeding means better healing quickly.
- LESS PAIN – As parents, our primary concern for our children is related to pain. CO2 lasers used on other oral soft tissues have been shown to result in significantly less pain during post-op healing (Zeini Jahromi et al, 2017). Less pain means better breastfeeding, faster.
- BETTER BREASTFEEDING – For moms who are breastfeeding, a primary goal of lip-tie or tongue-tie revision is improve the quality and efficiency of breastfeeding, often to make sure that our youngest guest is gaining weight at a normal and healthy pace. Use of CO2 lasers in oral soft tissues have been shown to have the lowest number of functional complications during post-op healing. Fewer complications means more function, and better breastfeeding (Zeini Jahromi, 2017).
Raymond J. Tseng DDS, PhD
American Academy of Pediatric Dentistry
American Academy of Pediatrics, Section on Oral Health
American Academy of Pediatrics, Section on Breastfeeding
International Lactation Consultants Association (Credentialing body for IBCLC certification)
US Lactation Consultant Association
Tongue-Tie Lip-Tie Support Network Preferred Provider (application pending)
Tongue Tie Babies Support Network (Facebook)
Tongue and Lip Tie Support of NC/SC
- Mini-Externship, Bobby Ghaheri MD, Private Practice, Gresham, Oregon
- Training in pediatric craniofacial growth and development, UNC Hospitals
- Pediatric Tongue and Lip Ties – Robert Convissar DDS, Marty Kaplan DMD, Tufts University School of Dentistry
- Clinical rotations with Pediatric Medicine and ENT, UNC Hospitals
- Lasers in Pediatric Dentistry: Hard and Softt Tissue Applications – Robert Convissar DDS, Marty Kaplan DMD, Boston University School of Dental Medicine
- Frenums to Pacifiers, Pearls for treating toddlers- Bobak Ghaheri MD, AAPD Pre-conference course